Chest pain is the second most common complaint in the emergency department. The need to diagnose the cause of chest pain in a timely manner and appropriately direct care is crucial. Topics for discussion This article discusses the role of imaging in acute chest pain, after first differentiating chest pain into cardiac and non-cardiac causes with upfront clinical and biochemical assessment. The role of non-invasive imaging including point-of-care ultrasound, echocardiography, myocardial perfusion imaging, cardiac MRI, coronary computed tomography angiography (CCTA) and novel cardiac CT applications are discussed. Updates in the literature regarding the role of coronary plaque imaging in acute chest pain are reviewed, as are ongoing challenges and future directions. This includes a discussion on the yield of diagnostic testing in low-risk acute chest pain cohorts versus intermediate-high risk cohorts. The incremental value of further testing in the former is low, which is reflected in contemporary guidelines that discourage the use of costly diagnostic tests in these cohorts. In the latter cohort, emerging evidence has shown specifically the role CCTA could play in reducing the need for invasive coronary angiography in selective patients where the true probability of ACS is thought to be low.

Real-world considerations such as accessibility and affordability are also discussed in the paper because while guidelines offer clinicians the flexibility of evidence-based choice, physician decision must necessarily be made in consideration of real-world constraints.